CASE CONFERENCES The Expert Clinician Section Editors: Jess Mandel, M.D. and Peter Clardy, M.D.
A Young Man with Fever, Pleuritic Chest Pain, and a Lung Mass Shikha Gupta1, Ruxandra C. Ionescu1, Tim Lahm1,2, and Ninotchka L. Sigua1 1 Division of Pulmonary, Allergy, Critical Care, Occupational, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana; and 2Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
In Brief A young male cigarette smoker was hospitalized with a 2-week history of fever, dyspnea, hemoptysis, and left pleuritic chest pain. Radiographic chest imaging revealed a large left lung mass with a loculated pleural effusion. Routine cultures of sputum, blood, and urine were negative.
A 24-year-old man was admitted to community hospital 2 weeks after onset of fever with chills and night sweats, dyspnea, hemoptysis, and left pleuritic chest pain. He had a history of mild intermittent asthma and was currently smoking cigarettes. The patient’s initial chest radiograph at the other hospital reportedly showed left-sided consolidation with an air–fluid level. After initiation of treatment with vancomycin, piperacillin-tazobactam, and levofloxacin for a presumed lung abscess, he was transferred to our facility in Indianapolis, Indiana for further management. At the time of transfer, he was afebrile. The heart rate was 77 beats per minute. He was breathing comfortably at 16 breaths per minute with an oxygen saturation of 98% on ambient air. Chest examination revealed diminished breath sounds over the left hemithorax with associated dullness to percussion. The rest of the examination was unremarkable. Laboratory studies disclosed a hemoglobin level of 9.9 g/dl and a white blood cell count of 8,600 cells/ml with a normal differential. Results of routine
bacterial cultures of blood, urine, and sputum were negative. The initial chest radiograph at our facility revealed complete opacification of the left hemithorax (Figure 1A). Chest computed tomography scan demonstrated a left-sided multiloculated effusion associated with a large mixed-density mass showing focal
areas of necrosis and endobronchial extension into the left main bronchus (Figures 1B–1D). A thoracentesis was performed. Pleural fluid analysis revealed an exudative pleural effusion with total nucleated cells of 381,500/ml (100% polymorphonuclear cells). The fluid pH was 7.25, glucose level
Figure 1. Imaging studies. (A) Chest radiograph shows complete opacification of the left hemithorax. (B–D) Contrast-enhanced computed tomography scan of the chest shows a large left-sided multiloculated pleural effusion (black arrows) with a large mixed-density lesion (white arrows) in the lung showing areas of necrosis and endobronchial extension into the left mainstem bronchus.
(Received in original form December 13, 2013; accepted in final form June 15, 2014 ) Correspondence and requests for reprints should be addressed to Shikha Gupta, M.D., University of Pittsburgh Medical Center, 3459 Fifth Avenue, NW 628, Pittsburgh, PA 15213. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 8, pp 1316–1318, Oct 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201312-445CC Internet address: www.atsjournals.org
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AnnalsATS Volume 11 Number 8 | October 2014
CASE CONFERENCES was 35 mg/dl, lactate dehydrogenase level was 46,619 units/L, and total protein level was 3.17 mg/dl. Pleural fluid culture and cytology results were negative.
Questions 1. What is the differential diagnosis? 2. What is the next step in the management of the patient?
Diagnostic Reasoning and Evaluation The differential diagnosis for this young man’s chest disease is broad. He presented with a subacute course of illness and a lung mass accompanied by a pleural effusion. The pleural effusion was exudative, with a high concentration of polymorphonuclear leukocytes, lactate dehydrogenase level greater than 1,000 units/L, and low pH. These findings are most consistent with an infectious process. The presence of welldemarcated lung mass and the subacute course of illness argue against a typical community-acquired pneumonia and are suggestive instead of an anaerobic lung abscess; less common lung infections, such as histoplasmosis, cryptococcidiomycosis, nocardiomycosis, or actinomycosis; or infection by a parasite, such as Dirofilaria. In Indianapolis, we also consider blastomycosis. The irregular shape and heterogeneity of the lung mass and the negative sputum cultures raise consideration of a malignancy. In a young man, testicular cancer, lymphoma, and sarcomas come to mind. Bronchoscopy was performed and revealed an endobronchial lesion completely occluding the left main bronchus (Figure 2). Under light microscopy, stained samples of biopsy tissue revealed a biphasic tumor with an epithelial component and a stromal component (mesenchymal and cartilaginous). Brain magnetic resonance and testicular ultrasound imaging were unremarkable. These findings, considered together with the clinical presentation and radiographic features of the tumor, led to a diagnosis of pulmonary blastoma. Positron emission tomography was performed for tumor staging and revealed increased uptake in the mass without evidence of abnormal activity outside the lung. Case Conferences: The Expert Clinician
Figure 2. Bronchoscopy image of left main bronchus reveals an endobronchial lesion completely occluding the left upper lobe bronchus.
Discussion Pulmonary blastoma is a rare sarcomatoid lung neoplasm, composing about 0.25 to 0.5% of primary lung cancers. The first case was described in 1945 by Barrett and Barnard and was termed as “embryoma of the lung” because the histological appearance of the tumor was believed to resemble first trimester fetal lung. In 1961, this neoplasm was recategorized as pulmonary blastoma (1). Pulmonary blastoma is divided into two categories: biphasic (also known as classic biphasic pulmonary blastoma) and monophasic. The term biphasic refers here to the dual presence of epithelial and stromal components within the mass of the tumor. The epithelial component consists of tubular adenocarcinoma, typically resembling first trimester fetal lung. Loose undifferentiated mesenchymal cells with foci of osteosarcoma, chondrosarcoma, or rhabdomyosarcoma characterize the stromal component. Immunohistochemistry may be helpful in differentiating the epithelial and stromal components (2). Monophasic blastoma is further divided into well-differentiated fetal adenocarcinoma and pleuropulmonary blastoma (2). In the 2004 WHO classification of tumors, welldifferentiated fetal adenocarcinoma was reclassified as a distinctive adenocarcinoma variant.
The majority of patients with biphasic pulmonary blastoma are adults, with an average age at diagnosis of 43 years. Both unimodal age distribution with a peak in the fourth decade, as well as a bimodal distribution with peaks in the first and seventh decade, have been reported (3, 4). A male predominance has been reported, with a male-to-female ratio of 1.5:1. The etiology of biphasic pulmonary blastoma has not been identified. About 82% of patients have a history of tobacco use. Adducts of benzopyrene (a by-product of tobacco use) have been detected in the tumor (5). Pulmonary blastoma has also been linked to the p53 gene mutation (6). Common presenting symptoms include cough (33%), chest pain (31%), and hemoptysis (20%). Up to 40% of patients have been reported to be asymptomatic at diagnosis. Less common presenting symptoms include dyspnea, fever, weight loss, fatigue, spontaneous pneumothorax, and pleural effusions (2, 7, 8). The clinical presentation usually mimics a respiratory tract infection, which commonly leads to a delay in diagnosis. The most common radiological presentation is a unilateral, solitary, peripheral nodule or mass in an upper lobe (7). The tumor size can range from 1.5 to 13 cm and can be large enough to completely opacify the hemithorax (as seen in our patient). The characteristic 1317
CASE CONFERENCES appearance on chest computed tomography scan is a mixed solid and cystic lesion with variable contrast enhancement and necrotic center. Endobronchial involvement has been reported in 25% of patients (9). The tumor can involve the pleura and cause pleural effusions. Pleural and mediastinal involvement are indicative of metastasis. Diagnosis of biphasic pulmonary blastoma typically requires surgical resection, because specimens obtained by bronchoscopy are generally too small to fully characterize the pleomorphic nature of the tumor. The diagnosis of pulmonary blastoma on bronchoscopy should be strongly considered if two different cell lines are present on histologic examination. Surgical resection is the treatment of choice for biphasic pulmonary blastoma (3, 4). For patients with localized disease, surgery has been shown to prolong median survival from 2 to 33 months. Evidence of benefit of other modalities such as chemotherapy and radiation is anecdotal. Most authors of previous reports have recommended treatment with a combination of alkylating agents, antibiotics, or antimitotic agents, based on the regimens used for other tumors with similar histology (10). A few studies have claimed up to 26% response rate to these chemotherapeutic agents. A few case reports have also described successful use of neoadjuvant chemotherapy and radiotherapy to downstage the tumor before surgery, and others have reported success with radiation therapy as the sole modality of treatment (5, 11, 12). Biphasic pulmonary blastoma is an aggressive tumor and carries a poor prognosis, with a high incidence of recurrence within 12 months. Survival rates at 2, 5, and 10 years have been estimated at
Figure 3. Histological studies. Left pneumonectomy specimen shows epithelial component (white arrow) and stromal components: mesenchymal (black arrow) and cartilaginous (red arrow). (A) Hematoxylin-eosin stain at a lower magnification (310); (B) Hematoxylin-eosin stain at a higher magnification (320).
33, 16, and 8%, respectively. Adverse prognostic factors include tumor size (.5 cm), presence of metastasis on initial presentation, and tumor recurrence (2).
Final Diagnosis Biphasic pulmonary blastoma.
Insights: d
Follow-Up The patient underwent a left pneumonectomy with mediastinal lymph node resection. Gross pathological examination of the resected specimen revealed a 15 3 9 3 5 cm mixed cysticsolid mass involving the left upper and lower lobes, with extension beyond the bronchial margins. There was no evidence of metastasis in lymph nodes, pleura, or chest wall. Representative pathology images consistent with biphasic pulmonary blastoma are depicted in Figure 3. The patient recovered uneventfully from surgery and was discharged home. He
References 1 Barnard WG. Embryoma of lungs. Thorax 1952;7:299–301. 2 Van Loo S, Boeykens E, Stappaerts I, Rutsaert R. Classic biphasic pulmonary blastoma: a case report and review of the literature. Lung Cancer 2011;73:127–132. 3 Koss MN, Hochholzer L, O’Leary T. Pulmonary blastomas. Cancer 1991;67:2368–2381. 4 Larsen H, Sørensen JB. Pulmonary blastoma: a review with special emphasis on prognosis and treatment. Cancer Treat Rev 1996;22: 145–160. 5 Surmont VF, van Klaveren RJ, Nowak PJCM, Zondervan PE, Hoogsteden HC, van Meerbeeck JP. Unexpected response of a pulmonary blastoma on radiotherapy: a case report and review of the literature. Lung Cancer 2002;36:207–211. 6 Bodner SM, Koss MN. Mutations in the p53 gene in pulmonary blastomas: immunohistochemical and molecular studies. Hum Pathol 1996;27:1117–1123.
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was lost initially to follow-up but returned 4 months later with mediastinal and chest wall invasion by recurrent tumor. Chemotherapy with cisplatin and etoposide was initiated; however, he was again lost to follow-up.
d
d
d
Biphasic pulmonary blastoma is a rare, aggressive sarcomatoid lung neoplasm. Biphasic pulmonary blastoma typically presents as a large upper lobe peripheral nodule or mass. Surgical resection is the treatment of choice for localized biphasic pulmonary blastoma. Chemotherapy and radiation therapy have been used in nonsurgical candidates. Biphasic pulmonary blastoma carries a poor prognosis, with 5-year survival rate of 16%. n
Author disclosures are available with the text of this article at www.atsjournals.org.
7 Walker RI, Suvarna K, Matthews S. Case report: pulmonary blastoma: presentation of two atypical cases and review of the literature. Br J Radiol 2005;78:437–440. 8 Shyamkumar N, Athyal R, Govindarajulu G, Narayan V, Rangad F, Govil S, Chacko J. Pneumothorax preceding pulmonary blastoma in a child. Australas Radiol 2001;45:387–389. 9 Wang J, Sun H, Bai R, Liu H, Yu T. Pulmonary blastoma with endobronchial growth. J Thorac Oncol 2009;4:543–544. 10 Cutler CS, Michel RP, Yassa M, Langleben A. Pulmonary blastoma: case report of a patient with a 7-year remission and review of chemotherapy experience in the world literature. Cancer 1998;82:462–467. 11 Kouvaris JR, Gogou PV, Papacharalampous XN, Kostara HJ, Balafouta MJ, Vlahos LJ. Solitary brain metastasis from classic biphasic pulmonary blastoma: a case report and review of the literature. Onkologie 2006;29:568–570. 12 Zagar TM, Blackwell S, Crawford J, D’Amico T, Christensen JD, Sporn TA, Kelsey CR. Preoperative radiation therapy and chemotherapy for pulmonary blastoma: a case report. J Thorac Oncol 2010;5:282–283.
AnnalsATS Volume 11 Number 8 | October 2014
A Young Man with Fever, Pleuritic Chest Pain, and a Lung Mass Shikha Gupta1, Ruxandra C. Ionescu1, Tim Lahm1,2, and Ninotchka L. Sigua1 1 Division of Pulmonary, Allergy, Critical Care, Occupational, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana; and 2Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
In Brief A young male cigarette smoker was hospitalized with a 2-week history of fever, dyspnea, hemoptysis, and left pleuritic chest pain. Radiographic chest imaging revealed a large left lung mass with a loculated pleural effusion. Routine cultures of sputum, blood, and urine were negative.
A 24-year-old man was admitted to community hospital 2 weeks after onset of fever with chills and night sweats, dyspnea, hemoptysis, and left pleuritic chest pain. He had a history of mild intermittent asthma and was currently smoking cigarettes. The patient’s initial chest radiograph at the other hospital reportedly showed left-sided consolidation with an air–fluid level. After initiation of treatment with vancomycin, piperacillin-tazobactam, and levofloxacin for a presumed lung abscess, he was transferred to our facility in Indianapolis, Indiana for further management. At the time of transfer, he was afebrile. The heart rate was 77 beats per minute. He was breathing comfortably at 16 breaths per minute with an oxygen saturation of 98% on ambient air. Chest examination revealed diminished breath sounds over the left hemithorax with associated dullness to percussion. The rest of the examination was unremarkable. Laboratory studies disclosed a hemoglobin level of 9.9 g/dl and a white blood cell count of 8,600 cells/ml with a normal differential. Results of routine
bacterial cultures of blood, urine, and sputum were negative. The initial chest radiograph at our facility revealed complete opacification of the left hemithorax (Figure 1A). Chest computed tomography scan demonstrated a left-sided multiloculated effusion associated with a large mixed-density mass showing focal
areas of necrosis and endobronchial extension into the left main bronchus (Figures 1B–1D). A thoracentesis was performed. Pleural fluid analysis revealed an exudative pleural effusion with total nucleated cells of 381,500/ml (100% polymorphonuclear cells). The fluid pH was 7.25, glucose level
Figure 1. Imaging studies. (A) Chest radiograph shows complete opacification of the left hemithorax. (B–D) Contrast-enhanced computed tomography scan of the chest shows a large left-sided multiloculated pleural effusion (black arrows) with a large mixed-density lesion (white arrows) in the lung showing areas of necrosis and endobronchial extension into the left mainstem bronchus.
(Received in original form December 13, 2013; accepted in final form June 15, 2014 ) Correspondence and requests for reprints should be addressed to Shikha Gupta, M.D., University of Pittsburgh Medical Center, 3459 Fifth Avenue, NW 628, Pittsburgh, PA 15213. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 8, pp 1316–1318, Oct 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201312-445CC Internet address: www.atsjournals.org
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AnnalsATS Volume 11 Number 8 | October 2014
CASE CONFERENCES was 35 mg/dl, lactate dehydrogenase level was 46,619 units/L, and total protein level was 3.17 mg/dl. Pleural fluid culture and cytology results were negative.
Questions 1. What is the differential diagnosis? 2. What is the next step in the management of the patient?
Diagnostic Reasoning and Evaluation The differential diagnosis for this young man’s chest disease is broad. He presented with a subacute course of illness and a lung mass accompanied by a pleural effusion. The pleural effusion was exudative, with a high concentration of polymorphonuclear leukocytes, lactate dehydrogenase level greater than 1,000 units/L, and low pH. These findings are most consistent with an infectious process. The presence of welldemarcated lung mass and the subacute course of illness argue against a typical community-acquired pneumonia and are suggestive instead of an anaerobic lung abscess; less common lung infections, such as histoplasmosis, cryptococcidiomycosis, nocardiomycosis, or actinomycosis; or infection by a parasite, such as Dirofilaria. In Indianapolis, we also consider blastomycosis. The irregular shape and heterogeneity of the lung mass and the negative sputum cultures raise consideration of a malignancy. In a young man, testicular cancer, lymphoma, and sarcomas come to mind. Bronchoscopy was performed and revealed an endobronchial lesion completely occluding the left main bronchus (Figure 2). Under light microscopy, stained samples of biopsy tissue revealed a biphasic tumor with an epithelial component and a stromal component (mesenchymal and cartilaginous). Brain magnetic resonance and testicular ultrasound imaging were unremarkable. These findings, considered together with the clinical presentation and radiographic features of the tumor, led to a diagnosis of pulmonary blastoma. Positron emission tomography was performed for tumor staging and revealed increased uptake in the mass without evidence of abnormal activity outside the lung. Case Conferences: The Expert Clinician
Figure 2. Bronchoscopy image of left main bronchus reveals an endobronchial lesion completely occluding the left upper lobe bronchus.
Discussion Pulmonary blastoma is a rare sarcomatoid lung neoplasm, composing about 0.25 to 0.5% of primary lung cancers. The first case was described in 1945 by Barrett and Barnard and was termed as “embryoma of the lung” because the histological appearance of the tumor was believed to resemble first trimester fetal lung. In 1961, this neoplasm was recategorized as pulmonary blastoma (1). Pulmonary blastoma is divided into two categories: biphasic (also known as classic biphasic pulmonary blastoma) and monophasic. The term biphasic refers here to the dual presence of epithelial and stromal components within the mass of the tumor. The epithelial component consists of tubular adenocarcinoma, typically resembling first trimester fetal lung. Loose undifferentiated mesenchymal cells with foci of osteosarcoma, chondrosarcoma, or rhabdomyosarcoma characterize the stromal component. Immunohistochemistry may be helpful in differentiating the epithelial and stromal components (2). Monophasic blastoma is further divided into well-differentiated fetal adenocarcinoma and pleuropulmonary blastoma (2). In the 2004 WHO classification of tumors, welldifferentiated fetal adenocarcinoma was reclassified as a distinctive adenocarcinoma variant.
The majority of patients with biphasic pulmonary blastoma are adults, with an average age at diagnosis of 43 years. Both unimodal age distribution with a peak in the fourth decade, as well as a bimodal distribution with peaks in the first and seventh decade, have been reported (3, 4). A male predominance has been reported, with a male-to-female ratio of 1.5:1. The etiology of biphasic pulmonary blastoma has not been identified. About 82% of patients have a history of tobacco use. Adducts of benzopyrene (a by-product of tobacco use) have been detected in the tumor (5). Pulmonary blastoma has also been linked to the p53 gene mutation (6). Common presenting symptoms include cough (33%), chest pain (31%), and hemoptysis (20%). Up to 40% of patients have been reported to be asymptomatic at diagnosis. Less common presenting symptoms include dyspnea, fever, weight loss, fatigue, spontaneous pneumothorax, and pleural effusions (2, 7, 8). The clinical presentation usually mimics a respiratory tract infection, which commonly leads to a delay in diagnosis. The most common radiological presentation is a unilateral, solitary, peripheral nodule or mass in an upper lobe (7). The tumor size can range from 1.5 to 13 cm and can be large enough to completely opacify the hemithorax (as seen in our patient). The characteristic 1317
CASE CONFERENCES appearance on chest computed tomography scan is a mixed solid and cystic lesion with variable contrast enhancement and necrotic center. Endobronchial involvement has been reported in 25% of patients (9). The tumor can involve the pleura and cause pleural effusions. Pleural and mediastinal involvement are indicative of metastasis. Diagnosis of biphasic pulmonary blastoma typically requires surgical resection, because specimens obtained by bronchoscopy are generally too small to fully characterize the pleomorphic nature of the tumor. The diagnosis of pulmonary blastoma on bronchoscopy should be strongly considered if two different cell lines are present on histologic examination. Surgical resection is the treatment of choice for biphasic pulmonary blastoma (3, 4). For patients with localized disease, surgery has been shown to prolong median survival from 2 to 33 months. Evidence of benefit of other modalities such as chemotherapy and radiation is anecdotal. Most authors of previous reports have recommended treatment with a combination of alkylating agents, antibiotics, or antimitotic agents, based on the regimens used for other tumors with similar histology (10). A few studies have claimed up to 26% response rate to these chemotherapeutic agents. A few case reports have also described successful use of neoadjuvant chemotherapy and radiotherapy to downstage the tumor before surgery, and others have reported success with radiation therapy as the sole modality of treatment (5, 11, 12). Biphasic pulmonary blastoma is an aggressive tumor and carries a poor prognosis, with a high incidence of recurrence within 12 months. Survival rates at 2, 5, and 10 years have been estimated at
Figure 3. Histological studies. Left pneumonectomy specimen shows epithelial component (white arrow) and stromal components: mesenchymal (black arrow) and cartilaginous (red arrow). (A) Hematoxylin-eosin stain at a lower magnification (310); (B) Hematoxylin-eosin stain at a higher magnification (320).
33, 16, and 8%, respectively. Adverse prognostic factors include tumor size (.5 cm), presence of metastasis on initial presentation, and tumor recurrence (2).
Final Diagnosis Biphasic pulmonary blastoma.
Insights: d
Follow-Up The patient underwent a left pneumonectomy with mediastinal lymph node resection. Gross pathological examination of the resected specimen revealed a 15 3 9 3 5 cm mixed cysticsolid mass involving the left upper and lower lobes, with extension beyond the bronchial margins. There was no evidence of metastasis in lymph nodes, pleura, or chest wall. Representative pathology images consistent with biphasic pulmonary blastoma are depicted in Figure 3. The patient recovered uneventfully from surgery and was discharged home. He
References 1 Barnard WG. Embryoma of lungs. Thorax 1952;7:299–301. 2 Van Loo S, Boeykens E, Stappaerts I, Rutsaert R. Classic biphasic pulmonary blastoma: a case report and review of the literature. Lung Cancer 2011;73:127–132. 3 Koss MN, Hochholzer L, O’Leary T. Pulmonary blastomas. Cancer 1991;67:2368–2381. 4 Larsen H, Sørensen JB. Pulmonary blastoma: a review with special emphasis on prognosis and treatment. Cancer Treat Rev 1996;22: 145–160. 5 Surmont VF, van Klaveren RJ, Nowak PJCM, Zondervan PE, Hoogsteden HC, van Meerbeeck JP. Unexpected response of a pulmonary blastoma on radiotherapy: a case report and review of the literature. Lung Cancer 2002;36:207–211. 6 Bodner SM, Koss MN. Mutations in the p53 gene in pulmonary blastomas: immunohistochemical and molecular studies. Hum Pathol 1996;27:1117–1123.
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was lost initially to follow-up but returned 4 months later with mediastinal and chest wall invasion by recurrent tumor. Chemotherapy with cisplatin and etoposide was initiated; however, he was again lost to follow-up.
d
d
d
Biphasic pulmonary blastoma is a rare, aggressive sarcomatoid lung neoplasm. Biphasic pulmonary blastoma typically presents as a large upper lobe peripheral nodule or mass. Surgical resection is the treatment of choice for localized biphasic pulmonary blastoma. Chemotherapy and radiation therapy have been used in nonsurgical candidates. Biphasic pulmonary blastoma carries a poor prognosis, with 5-year survival rate of 16%. n
Author disclosures are available with the text of this article at www.atsjournals.org.
7 Walker RI, Suvarna K, Matthews S. Case report: pulmonary blastoma: presentation of two atypical cases and review of the literature. Br J Radiol 2005;78:437–440. 8 Shyamkumar N, Athyal R, Govindarajulu G, Narayan V, Rangad F, Govil S, Chacko J. Pneumothorax preceding pulmonary blastoma in a child. Australas Radiol 2001;45:387–389. 9 Wang J, Sun H, Bai R, Liu H, Yu T. Pulmonary blastoma with endobronchial growth. J Thorac Oncol 2009;4:543–544. 10 Cutler CS, Michel RP, Yassa M, Langleben A. Pulmonary blastoma: case report of a patient with a 7-year remission and review of chemotherapy experience in the world literature. Cancer 1998;82:462–467. 11 Kouvaris JR, Gogou PV, Papacharalampous XN, Kostara HJ, Balafouta MJ, Vlahos LJ. Solitary brain metastasis from classic biphasic pulmonary blastoma: a case report and review of the literature. Onkologie 2006;29:568–570. 12 Zagar TM, Blackwell S, Crawford J, D’Amico T, Christensen JD, Sporn TA, Kelsey CR. Preoperative radiation therapy and chemotherapy for pulmonary blastoma: a case report. J Thorac Oncol 2010;5:282–283.
AnnalsATS Volume 11 Number 8 | October 2014
